Approximately 20% of patients with abdominal aortic aneurysm (AAA) have diabetes mellitus (DM). The diagnosis of DM in patients with a small AAA has been associated with an over 20% reduction in the growth of the AAA maximal transverse diameter (MTD) that has been attributed to less active aortic matrix degeneration. After the exclusion of AAAs with endografts, it is not known whether DM is associated with an alteration in the behavior of the residual sac. We hypothesized that patients with DM would demonstrate greater regression of the sac after endovascular AAA repair.

Objective: The aim of our prospective, single-center, randomized study was to compare the procedural outcomes and complication rates of ultrasound (US)-guided common femoral artery (CFA) access to fluoroscopic guidance in noncardiac procedures. Methods: A total of 635 patients undergoing femoral access for noncardiac diagnostic or interventional procedures were randomized 1:1 to receive either fluoroscopic or US-guided access. The primary end point of the study was successful CFA cannulation. Secondary end points included the first-pass success rate, time to sheath insertion, and accidental venipunctures rate. Both short (24 hours) and midterm (30-90 days postprocedure) access complications were assessed by practitioners blinded to patient randomization. Results: Successful CFA cannulation occurred in 93% of US-guided procedures compared with 86% of fluoroscopyguided access (P = .002). US guidance was associated with increased rates of first-attempt success (74% vs 42%; P <.001), fewer inadvertent venipunctures (2% vs 10 %; P <.001), and decreased median time to cannulation (80 vs 100 seconds; P <.001) compared with fluoroscopy. Rates of complications did not differ at 24 hours (1% vs 1%; P = .99) or 30 to 90 days (2% vs 4%; P = .15) in fluoroscopy vs US-guided access. When access was performed by vascular surgery trainees (residents and fellows), US guidance retained superior rates of successful CFA cannulation compared to fluoroscopy guided access (n = 298; 96% vs 89%; P = .03). Trainees' time to achieve CFA cannulation was similar to attendings' when using US guidance (median, 85 vs 77 seconds; P = .14); however, with fluoroscopy, trainees' times were significantly longer than those of attendings (137 vs 86 seconds; P = .001). Conclusions: In comparison to fluoroscopy, US-guided CFA cannulation had a higher rate of success, faster cannulation, and fewer venipunctures in the absence of increased complications.

Background: Several studies have demonstrated better outcomes for carotid endarterectomy with high-volume hospitals and providers. However, only a few studies have reported on the impact of operator specialty/volume on the perioperative outcome of carotid artery stenting (CAS). This study will analyze the correlation of CAS outcomes and provider specialty and volume. Methods: Prospectively collected data of CAS procedures done at our institution during a 10-year period were analyzed. Major adverse events (MAEs; 30-day stroke, myocardial infarction, and death) were compared according to provider specialty (vascular surgeons [VSs], interventional cardiologists [ICs], interventional radiologists [IRs], interventional vascular medicine [IVM]), and volume (>= 5 CAS/year vs. < 5 CAS/year). Results: Four hundred fourteen CAS procedures (44% for symptomatic indications) were analyzed. Demographics/clinical characteristics were somewhat similar between specialties. MAE rates were not significantly different between various specialties: 3.1% for IC, 6.3% for VS, 7.1% for IR, 6.7% for IVM (P = 0.3121; 6.3% for VS and 3.8% for others combined, P = 0.2469). When physicians with < 5 CAS/year were excluded: the MAE rates were 3.1% for IC, 4.7% for VS, and 6.7% for IVM (P = 0.5633). When VS alone were compared with others, and physicians with < 5 CAS/year were excluded, the MAE rates were 4.7% for VS vs. 3.6% for non-VS (P = 0.5958). The MAE rates for low-volume providers, regardless of their specialty, were 9.5% vs. 4% for high-volume providers (P = 0.1002). Logistic regression analysis showed that the odds ratio of MAE was 0.4 (0.15-1.1, P = 0.0674) for high-volume providers, while the odds ratio for VS was 1.3 (0.45-3.954, P = 0.5969). Conclusions: Perioperative MAE rates for CAS were similar between various providers, regardless of specialties, particularly for vascular surgeons with similar volume to non-vascular surgeons. Low-volume providers had higher MAE rates.

BACKGROUND: Post-endovascular aortic aneurysm repair (EVAR) endoleaks and the need for reintervention are challenging. Additional endovascular treatment is advised for type Ia endoleaks detected on post-EVAR completion angiogram. This study analyzed management and late outcomes of these endoleaks.STUDY DESIGN: This was a retrospective review of prospectively collected data from EVAR patients during a 10-year period. All post-EVAR type Ia endoleaks on completion angiogram were identified (group A) and their early (30-day) and late outcomes were compared with outcomes of patients without endoleaks (group B). Kaplan-Meier analysis was used for survival analysis, sac expansion, late type Ia endoleak, and reintervention.RESULTS: Seventy-one of 565 (12.6%) patients had immediate post-EVAR type Ia endoleak. Early intervention (proximal aortic cuffs and/or stenting) was used in 56 of 71 (79%) in group A vs 31 of 494 (6%) in group B (p < 0.0001). Late type Ia endoleak was noted in 9 patients (13%) in group A at a mean follow-up of 28 months vs 10 patients (2%) in group B at a mean follow-up of 32 months (p < 0.0001). Late sac expansion and reintervention rates were 9% and 10% for group A vs 5% and 3% for group B (p = 0.2698 and p = 0.0198), respectively. Freedom rates from late type Ia endoleaks at 1, 3, and 5 years for group A were 88%, 85%, and 80% vs 98%, 98%, and 96% for group B (p < 0.001); and for late intervention, were 94%, 92%, and 77% for group A, and 99%, 97%, and 95% for group B (p = 0.007), respectively. Survival rates were similar.CONCLUSIONS: Immediate post-EVAR type Ia endoleaks are associated with higher rates of early interventions, late endoleaks and reintervention, which will necessitate strict post-EVAR surveillance. ((C) 2016 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: No criteria, including preamputation vascular diagnostic thresholds, have been established to reliably predict healing versus nonhealing following minor lower extremity amputations. Thus, the goal of our study was to identify clinical factors, including noninvasive vascular laboratory measures, associated with wound healing following toe, forefoot, and midfoot amputations. Methods: We retrospectively examined records of patients receiving elective toe, forefoot, or midfoot amputation at our institution over a 5-year span (2010-2015). A total of 333 amputations received noninvasive vascular assessment of the lower extremity preamputation and follow-up at 90 days postamputation. Multivariate binomial logistic regression was used to identify variables predicting wound healing as defined as the absence of reamputation due to wound breakdown. Results: Wound healing occurred in 81% of amputations. A total of 23 (7%) patients required revisions of the foot while 39 (12%) patients required major amputations by 90 days. Chi-squared analysis found that toe pressure at or above the value of 47mmHg (P = 0.04), bi/triphasic anterior tibial (P = 0.01), and posterior tibial artery (P = 0.01) waveforms were associated with wound healing. When these diagnostic parameters were examined in the presence of confounders (increasing age, chronic kidney disease, and concomitant revascularization), only toe pressure >= 47 mm Hg predicted amputation site healing (odds ratio: 3.1 [95% CI: 1.0-9.4], P = 0.04). Conclusion: Preamputation toe pressures of 47 mm Hg and above are associated with wound healing. No other noninvasive vascular studies predicted wound healing in the presence of confounders. Thus, toe pressures may assist in clinical decision-making and should be routinely obtained preamputation.

Background: A few other studies have reported the effects of anatomical and technical factors on clinical outcomes of carotid artery stenting (CAS). This study analyzed the effect of these factors on perioperative stroke/myocardial infarction/death after CAS.Methods: This was a retrospective analysis of prospectively collected data of 409 of 456 patients who underwent CAS during the study period. A logistic regression analysis was used to determine the effects of anatomical and technical factors on perioperative stroke, death, and myocardial infarction (major adverse events [MAEs]).Results: The MAE rate for the entire series was 4.7% (19 of 409), and the stroke rate was 2.2% (9 of 409). The stroke rate for asymptomatic patients was 0.46% (1 of 218; P = .01). The MAE rates for patients with transient ischemic attack (TIA) were 7% (11 of 158) vs 3.2% (8 of 251) for other indications (P = .077). The stroke rates for heavily calcified lesions were 6.3% (3 of 48) vs 1.2% (4 of 332) for mildly calcified/noncalcified lesions (P = .046). Differences in stroke and MAE rates regarding other anatomical features were not significant. The stroke rate for patients with percutaneous transluminal angioplasty (PTA) before embolic protection device (EPD) insertion was 9.1% (2 of 22) vs 1.8% (7 of 387) for patients without (P = .07) and 2.6% (9 of 341) for patients with poststenting PTA vs 0% (0 of 68) for patients without. The MAE rate for patients with poststenting PTA was 5.6% (19 of 341) vs 0% (0 of 68) for patients without (P = .0536). The MAE rate for patients with the ACCUNET (Abbott, Abbott Park, Ill) EPD was 1.9% (3 of 158) vs 6.7% (16 of 240) for others (P = .029). The differences between stroke and MAE rates for other technical features were not significant. A regression analysis showed that the odds ratio for stroke was 0.1 (P = .031) for asymptomatic indications, 13.7 (P = .014) for TIA indications, 6.1 (P = .0303) for PTA performed before EPD insertion, 1.7 for PTA performed before stenting, and 5.4 (P = .0315) for heavily calcified lesions. The MAE odds ratio was 0.46 (P = .0858) for asymptomatic indications, 2.1 for PTAs performed before EPD insertion, 2.2 for poststent PTAs, and 2.2 (P = .1888) for heavily calcified lesions. A multivariate analysis showed that patients with TIA had an odds ratio of stroke of 11.05 (P = .029). Patients with PTAs performed before EPD insertion had an OR of 6.15 (P = .062). Patients with heavily calcified lesions had an odds ratio of stroke of 4.25 (P = .0871). The MAE odds ratio for ACCUNET vs others was 0.27 (P = .0389).Conclusions: Calcific lesions and PTA before EPD insertion or after stenting were associated with higher stroke or MAE rates, or both. The ACCUNET EPD was associated with lower MAE rates. There was no correlation between other anatomical/technical variables and CAS outcome.

OBJECTIVE:A plethora of papers have been written regarding postcatheterization femoral pseudoaneurysms. However, literature is lacking on pseudoaneurysmal management in patients undergoing coronary artery bypass grafting (CABG). Thus, we examined if pseudoaneurysms with subsequent CABG can be managed with the same strategies as those not exposed to the intense anticoagulation accompanying CABGs. METHODS:During a 14-year study period, we retrospectively examined femoral iatrogenic pseudoaneurysms (IPSAs) diagnosed postheart catheterization in patients having a subsequent CABG. Patient information was obtained from electronic medical records and included pseudoaneurysm characteristics, treatment, and resolution. Outcomes of interest included the occurrence of IPSA treatment failures and complications. RESULTS:In the 66 patients (mean age, 66 ± 11 years, 46% male) meeting inclusion criteria, mean dose of heparin received during the CABG procedure was 34 000 ± 23 000 units. The IPSA size distribution was the following: 17% of IPSAs measured <1 cm, 55% between 1 and 3 cm, and 21% measured >3 cm. Pseudoaneurysms were managed with compression, duplex-guided thrombin injection, and surgical repair (1%, 27%, and 26% of cases, respectively). Thrombin injection and surgical repair were 100% effective at treating pseudoaneurysms, with 1 patient experiencing a surgical site infection postsurgical repair. Observation-only management was employed in 30 (45%) patients. Nine of 30 patients with no intervention beyond observation had duplex documented resolution/thrombosis during follow-up. One patient initially managed by observation required readmission and surgical repair of an enlarging pseudoaneurysm (6 cm growth) following CABG. CONCLUSION:Management of pseudoaneurysms in patients prior to CABG should be similar to those patients not undergoing intense anticoagulation. In appropriate cases, small aneurysms can be safely observed, while thrombin injections are effective and safe as well. Thus, routine open surgical repair is not routinely required in patients with femoral pseudoaneurysms at time of CABG.

Objective: Chronic venous ulcer (CVU) is a potentially debilitating condition that remains the most common etiology for leg ulcers. The condition has significant associated costs and effect on patient quality of life. That truncal reflux can be worsened by iliac vein occlusive disease is well known. However, there has not been systematic investigation of venous duplex ultrasound (VDUS) criteria to correlate common femoral vein (CFV) reflux with iliac vein stenosis. We sought to correlate VDUS criteria for predicting iliac vein stenosis and to investigate venous outflow factors associated with CVU recurrence.Methods: We conducted a systematic retrospective review of a consecutive series of 36 patients who received standard therapies, including compression therapy along with ablation of incompetent great saphenous veins for treating CVU, but in whom the treatment failed. Elevated CVF reflux was considered as reflux duration (RD) measured by VDUS to last >1 second. A receiver operator characteristic curve analysis was performed to determine the optimal CFV threshold value to predict 50% iliac vein stenosis measured by intravascular ultrasound.Results: The 36 patients presented with 54 CVUs on 38 limbs. The median (25th-75th quartiles) age was 61.2 (57.6-68.8) years, body mass index was 36.8 (25.2-52.3) kg/m(2), CFV RD was 2.7 (1.6-3.5) seconds, ulcer diameter was 4.2 (3.0-4.0) cm, and ulcer depth was 2.5 (2.0-3.0) mm. The optimal cutoff RD value was >2.5 seconds by receiver operator characteristic curve analysis, with an area under the curve of 0.77 (P = .001). CVUs associated with an RD >2.5 seconds had significantly more iliac vein stenosis >50% by intravascular ultrasound (24 of 30; 80%) than those with an RD <2.5 seconds (6 of 24; 25%; P < .001). Likewise, >50% stenosis for those above and below an RD >1 second was 61.4% vs 30%, respectively (P = .089). Significantly less recurrence of CVU was found for patients taking pentoxifylline (43.6% vs 80.0%; P = .031) and those with stents placed (40.0% vs 70.8%; P = .031). A nonsignificant trend was found for iliac vein interrogation (44.4% vs 72.2%; P = .082).Conclusions: This study highlights the utility of VDUS in diagnosing iliac vein stenosis with 2.5 seconds to predict >= 50% iliac vein stenosis. Stent placement and pentoxifylline were associated with ulcer healing and reduced risk of venous ulcer recurrence.

The purpose of our study was to determine outcome differences as a function of baseline high-sensitivity C-reactive protein (hsCRP) and B-type natriuretic peptide (BNP) levels in patients receiving lower extremity open reconstructions for the treatment of peripheral arterial occlusive disease. We retrospectively examined patients who underwent surgical reconstructions performed by a single operator during a seven-year time span who received preoperative hsCRP and BNP testing and post-procedure imaging. Outcomes of interest included major adverse limb events, a composite end point of target vessel revascularization, limb amputation, and disease progression, and major adverse cardiovascular events comprised of stroke, myocardial infarction, and death. A total of 89 limbs in 82 patients were included in analysis. Multivariate analysis demonstrated that higher hsCRP levels (>3.0 mg/L) trended toward, but failed to significantly associate with major adverse limb events at 24 months (hazard ratio: 2.2 [1.0–5.2], p = 0.06), however the use of a vein bypass conduit (vs. prosthetic reconstruction) significantly predicted major adverse limb events (hazard ratio: 3.2 [1.5–6.9], p < 0.01). Elevated BNP levels (>100 pg/ml), but not hsCRP, associated with major adverse cardiovascular events (hazard ratio: 3.5 [1.2–10.3], p = 0.03). Preoperative biochemical markers may assist in clinical decision making and stratifying patients regarding adverse events following open reconstructions.

Carotid artery stenting has been advocated as an alternative therapy to carotid endarterectomy in the treatment of patients with symptomatic and asymptomatic carotid stenosis, specifically for those at high risk for surgical revascularization.The impact of chronic renal insufficiency on the long-term clinical outcome of carotid artery stenting has not been well established. We have previously shown that although the perioperative carotid artery stenting stroke rates for normal, moderate, and severe chronic renal insufficiency were not significantly different using either serum creatinine or the glomerular filtration rate as markers, the long-term outcomes were somewhat different. The rates of freedom from major adverse events (stroke, myocardial infarction, and death) at 3 years in symptomatic patients were 81 % in patients with normal renal function versus 46 % in patients with moderate/severe chronic renal insufficiency (p = 0.0198). This study also showed that the glomerular filtration rate was more sensitive in detecting late major adverse events after carotid artery stenting than serum creatinine. This study concluded that carotid artery stenting in moderate chronic renal insufficiency patients can be done with satisfactory perioperative outcomes; however the late death rate was significantly high.

OBJECTIVE:Imaging surveillance after endovascular aortic aneurysm repair (EVAR) is critical. In this study we analyzed compliance with imaging surveillance after EVAR and its effect on clinical outcomes.METHODS:Retrospective analysis of prospectively collected data of 565 EVAR patients (August 2001-November 2013), who were followed using duplex ultrasound and/or computed tomography angiography. Patients were considered noncompliant (NC) if they did not have any follow-up imaging for 2 years and/or missed their first post-EVAR imaging over 6 months. A Kaplan-Meier analysis was used to compare compliance rates in EVAR patients with hostile neck (HN) vs favorable neck (FN) anatomy (according to instructions for use). A multivariate analysis was also done to correlate compliance and comorbidities.RESULTS:Forty-three percent were compliant (7% had no follow-up imaging) and 57% were NC. The mean follow-up for compliant patients was 25.4 months (0-119 months) vs 31.4 months for NC (0-140 months). The mean number of imaging was 3.5 for compliant vs 2.6 for NC (P < .0001). Sixty-four percent were NC for HN patients vs 50% for FN patients (P = .0007). The rates of compliance at 1, 2, 3, 4, and 5 years for all patients were 78%, 63%, 55%, 45%, and 32%; and 84%, 68%, 61%, 54%, and 40% for FN patients; and 73%, 57%, 48%, 37%, and 25% for HN patients (P = .009). The NC rate for patients with late endoleak and/or sac expansion was 58% vs 54% for patients with no endoleak (P = .51). The NC rate for patients with late reintervention was 70% vs 53% for patients with no reintervention (P = .1254). Univariate and multivariate analyses showed that patients with peripheral arterial disease had an odds ratio of 1.9 (P = .0331), patients with carotid disease had an odds ratio of 2 (P = .0305), and HN patients had an odds ratio of 1.8 (P = .0007) for NC. Age and residential locations were not factors in compliance.CONCLUSIONS:Overall, compliance of imaging surveillance after EVAR was low, particularly in HN EVAR patients, and additional studies are needed to determine if strict post-EVAR surveillance is necessary, and its effect on long-term clinical outcome.

BACKGROUD:To determine if elevated preintervention high-sensitivity C-reactive protein (hsCRP) and B-type natriuretic peptide (BNP) levels associate with major adverse cardiovascular events (MACE) or disease progression after carotid revascularization. METHODS:We retrospectively examined patients receiving elective carotid endarterectomy (CEA) or carotid artery stenting (CAS) at our institution from 2007 to 2014. All included patients had preintervention hsCRP and BNP levels. Examined outcomes of interest included contralateral carotid disease progression (increased stenosis or need for revascularization) and MACE (composite of death, stroke, myocardial infarction, need for coronary artery bypass graft or percutaneous coronary intervention) at 3 years after procedure. The relationship between baseline hsCRP and BNP levels and time to event was examined by univariate and multivariate Cox proportional hazard regression analyses. RESULTS:A total of 248 patients were included in the analysis (mean age: 68 ± 10 years), with 14% receiving CAS and 86% CEA. A total of 61 patients (25%) had 1 or more MACE by 3 years. Elevated hsCRP (>3 mg/L) trended toward associating with MACE but failed to reach significance (hazard ratio [HR]: 1.6 [1.0-2.7], P = 0.07). Multivariate analysis found that elevated BNP (>100pg/mL, HR: 2.2 [1.3-3.7], P = 0.002) and diabetes mellitus (HR: 1.9 [1.2-3.2], P = 0.01) predicted MACE. Having elevated preprocedural levels of both hsCRP and BNP significantly increased patients' likelihood of experiencing MACE (HR: 3.4 [1.6-7.1], P = 0.001). About 175 patients received contralateral carotid imaging postprocedure and of those patients, 31 (18%) experienced stenosis progression and/or revascularization within 3 years. However, neither elevated hsCRP (HR: 1.2 [0.6-2.3], P = 0.68) nor BNP (HR: 1.1 [0.5-2.5], P = 0.88) associated with disease progression. CONCLUSIONS:BNP elevation at the time of carotid intervention is associated with MACE in long-term follow-up. hsCRP does not appear to correlate with either disease progression of the contralateral artery or MACE.

OBJECTIVE:The purpose of this study was to identify significant predictors of long-term mortality after elective endovascular abdominal aortic aneurysm repair (EVAR). METHODS:We included all cases with elective EVAR based on a national data set from the Society for Vascular Surgery Patient Safety Organization. Clinical and anatomic variables were analyzed with a Kaplan-Meier and Cox-regression model to determine predictors of mortality and develop a score equation to categorize patients into low, medium, and high long-term mortality risk. RESULTS:A total of 5678 patients with EVAR were included with an average age of 73.6 ± 8.2 years. The majority were male (81.6%) with a history of smoking (86.1%). There were 3 deaths within 30 days (0.1%). Several factors were associated with poor survival: unstable angina (hazard ratio [HR], 2.8; P = .008), dialysis (HR, 3.7; P < .001), estimated glomerular filtration rate (eGFR) <30 (HR, 1.7; P = .044), eGFR 30 to 59 (HR, 1.4; P = .002), age >80 (HR, 3.2; P < .001), age 75 to 79 (HR, 2.2; P < .001), chronic obstructive pulmonary disease on oxygen (HR, 3.3; P < .001), aortic diameter >5.8 cm (HR, 1.2; P = .043), and high risk for surgery (HR, 1.4; P = .043). Preoperative aspirin use and body mass index 25 to 35 were both found to be protective (HR, 0.78; P = .017 and HR, 0.8; P = .024, respectively). With our scoring model, 5- and 10-year survival rates for patients with low, medium, and high risk were 89.2%, 80.7%, and 64.1% and 77.2%, 60.1%, and 40.1%, respectively (P < .001). CONCLUSION:Ten-year survival following EVAR in patients with a high-risk score utilizing the model provided was 40.1%. Patients with multiple comorbidities at risk for decreased long-term survival can be identified with our model, which is more applicable for high-volume contemporary institutions.

OBJECTIVETo compare with antibiotics with methicillin-resistant microbial coverage in a prospective fashion.BACKGROUNDCurrent antibiotic prophylaxis for vascular procedures includes a first generation cephalosporin. No changes in recommendations have occurred despite changes in reports of incidence of MRSA related surgical site infections. Does supplemental anti-MRSA prophylactic coverage provide a significant reduction in Gram-positive or MRSA infections?METHODSSingle center prospective double blinded randomized study of patients undergoing lower extremity vascular procedures from 2011 to 2014. One hundred seventy-eight (178) patients were evaluated at 90 days for surgical site infection. Infections were categorized as early infections less than 30 days of the index procedure and late after 90 days.RESULTSEarly vascular surgical site infection occurred in 7(8.24%) of patients in the Vancomycin arm, and 11 (11.83%) in the Daptomycin arm (P = 0.43). Gram-positive related infections and MRSA infections occurred in 1(1.18%)/0(0%) of Vancomycin patients and 9 (9.68%)/1 (1.08%) of Daptomycin patients, respectively (P < 0.02 and P = 1.00). Readmissions related to surgical site infections occurred in 4(4.71%) in the Vancomycin group and 11 (11.8%) in the Daptomycin group (P = 0.11). Patients undergoing operative exploration occurred in 5 (5.88%) in the Vancomycin group and 10 (10.75%) of the Daptomycin group (P = 0.17). Late infections were reported in 3 patients, 2 of which were in the combined Daptomycin group. Median hospital charges related to readmissions due to a surgical site infection was $50,823 in the combination Vancomycin arm and $110,920 in the combination Daptomycin group; however, no statistical significance was appreciated (P = 0.11).CONCLUSIONSVancomycin supplemental prophylaxis seems to reduce the incidence of Gram-positive infection compared with adding supplemental Daptomycin prophylaxis. The Incidence of MRSA-related surgical site infections is low with the addition of either anti-MRSA agents compared with historical incidence of MRSA-related infection.